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Medicare Coverage of Colonoscopy

What It Is

What's Covered

Medicare Part B covers an outpatient colonoscopy. How often Medicare Part B covers the procedure depends on the patient's medical history:

For people who are not considered at high risk for colorectal cancer, one test every ten years (but not within four years after a flexible sigmoidoscopy.

For people who are at high risk for colorectal cancer, based on their personal and family medical history, one test every two years.

If you have a Medicare Part C Medicare Advantage plan:Medicare Part C Medicare Advantage plans, also called Medicare Advantage plans, must cover everything that's included in original Medicare Part A and Part B coverage. But sometimes a Part C plan covers more, with extra services or an expanded amount of coverage. (Co-payments for Part C plans may also be different than those for Part A or Part B.) To find out whether your plan provides extra coverage or requires different co-payments for a colonoscopy, contact the plan directly.

What Medicare Pays

Medicare Part B pays 80 percent of the Medicare-approved amount for the procedure if performed at a doctor's office, clinic, or health center. If the procedure is performed in a hospital outpatient department or ambulatory surgical center, Medicare Part B pays 75 percent of the Medicare-approved amount.

Important: Regardless of the rules regarding any particular type of care, in order for Medicare Part A, Medicare Part B, or a Medicare Part C plan to provide coverage, the care must meet two basic requirements:

The care must be "medically necessary." This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or a Medicare Part C plan) agrees that the care is necessary and proper. For help getting your care covered, see FAQ: How Can I Increase the Odds That Medicare Will Cover My Medical Service?

The care must be performed or delivered by a healthcare provider who participates in Medicare.

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